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Transitional Care Management (TCM): Codes, Rules and CCM
What TCM covers, its 2-day and 7/14-day deadlines, and how it fits with CCM.
Short answer: Transitional care management (TCM) covers the 30 days beginning with discharge from a qualifying facility to a community setting. It requires contact within 2 business days, medication reconciliation by the visit, and a face-to-face visit within 14 calendar days for 99495 or 7 for 99496. One practitioner reports one TCM claim per patient per period.
In transitional care management, the practitioner accepts responsibility for the patient’s care at discharge, without a service gap, and supports the return to the community.
TCM is one discharge-linked claim. CCM may be reported during the same 30 days when its requirements are met and no time or effort counts twice.
TL;DR: transitional care management in five lines
What it is: one Medicare service covering the 30 days that start on the discharge day.
Who reports it: one practitioner, once per patient per TCM period.
The clock: a contact within 2 business days, then a visit inside the code’s window.
The codes: 99495 and 99496, split by decision-making level and visit deadline.
With CCM: allowed during the TCM period, with no minute counted twice.
Who qualifies for transitional care management
TCM requires discharge from one of these seven settings:
- Inpatient acute care hospital
- Inpatient psychiatric hospital
- Inpatient rehabilitation facility
- Long-term care hospital
- Skilled nursing facility
- Hospital outpatient observation or partial hospitalization
- Partial hospitalization at a community mental health center
The patient must return to a community setting: home, a domiciliary such as a group home, a nursing facility or an assisted living facility.
The patient also needs moderate or high complexity medical decision making for medical or psychosocial problems, judged under the 2023 CPT E/M guidelines on the problems addressed, the data reviewed and the risk of the patient’s management.
TCM codes: CPT 99495 and 99496 compared
The two transitional care management codes share the 2-business-day contact rule and differ on decision making and the visit deadline:
| Element | 99495 | 99496 |
|---|---|---|
| Medical decision making during the period | At least moderate | High |
| Face-to-face visit | Within 14 calendar days of discharge | Within 7 calendar days of discharge |
| High-complexity patient seen 8 to 14 calendar days after discharge | Can be reported if every other element is met: the descriptor requires at least moderate decision making and a visit within 14 calendar days | Cannot be reported: the visit is outside the 7-calendar-day window |
How the 30-day transitional care management period works
Within 2 business days: the interactive contact
The practitioner or clinical staff under their direction contacts the patient or caregiver by phone, email or face to face within 2 business days of discharge. Clinical staff must address the patient’s status and needs beyond scheduling.
If contact fails, document at least two separate, timely attempts and keep trying. TCM may still be reported if every other requirement is met, including an on-time visit.
Inside the code’s window: the face-to-face visit
One face-to-face visit must fall within the deadline its code sets, with medication reconciliation and management done on or before the visit date.
Through day 30: the non-face-to-face work
Across the 30 days, the practitioner and clinical staff must furnish the non-face-to-face services that are medically reasonable and necessary. The practitioner’s part can include reviewing the discharge information, following up on pending tests and treatments, talking with the clinicians taking up the patient’s problems, and establishing or re-establishing referrals. Auxiliary personnel can carry part of the work under the practitioner’s general supervision, subject to state law, scope of practice and the incident-to rules:
- communicating with the patient and with the agencies and community services the patient uses
- educating the patient, family or caregiver to support self-management and daily living
- assessing and supporting treatment adherence, including medication management
- finding community and health resources and helping the patient and family reach needed care
The minimum TCM record
| Record item | What to document |
|---|---|
| Discharge | Discharge date |
| Interactive contact | First interactive contact date; document separate, timely attempts if unsuccessful |
| Face-to-face visit | Visit date |
| Medical decision making | Level during the TCM period |
Billing CCM and other services during the TCM period
CMS’s CCM booklet (MLN909188, June 2025) allows CCM codes 99487, 99489, 99490 and 99491 to be reported for services provided during the 30-day TCM period, and the TCM booklet’s concurrent-billing table also lists the 99439 add-on. CMS adds two conditions: the services must be relevant and medically necessary, and time counted toward any other billed code cannot also count toward CCM.
- CCM initiation: the TCM face-to-face visit can serve as the initiating visit when the CCM billing practitioner performs it and discusses CCM.
- G0506: extensive assessment and care planning by that practitioner beyond the visit’s usual effort may support this once-only CCM care-planning add-on. Confirm with your MAC whether it can accompany 99495 or 99496.
CMS also lists managing care transitions, including follow-up after hospital and skilled nursing facility discharges, inside CCM’s scope of service, so care coordination after a discharge can count toward CCM when that time and effort are not also counted toward TCM.
CMS’s TCM booklet also lists other services a practice can bill concurrently with TCM when each is medically reasonable and necessary and no time or effort is counted more than once, among them end-stage renal disease services, home INR monitoring, anticoagulant management, and remote physiologic and therapeutic monitoring. CMS’s CCM booklet limits the monitoring to one or the other, not both, with any TCM service. End-stage renal disease services (90951 to 90970) cannot be combined with CCM: CMS does not allow CCM in the same service period.
How TCM fits with APCM, PIN and CHI
Advanced primary care management (APCM, G0556 to G0558) and TCM cannot come from the same practitioner for the same patient in the same month; a different practitioner may bill TCM, including one in the same practice.
The E/M visit within TCM can also serve as the initiating visit for the CMS programs principal illness navigation (PIN) and community health integration (CHI), when the practitioner who will bill PIN or CHI furnishes that visit. APCM vs CCM vs PCM compares the monthly programs.
Common TCM billing mistakes
Four TCM billing mistakes
“The TCM visit is billed as its own E/M.” It is part of TCM and is not reported separately.
“A visit after 14 days can still be TCM.” If the face-to-face visit misses the required timeframe, TCM cannot be billed.
“The practitioner who discharged the patient cannot bill TCM.” The same practitioner may discharge the patient, report the discharge services and bill TCM; only the face-to-face visit cannot fall on the day discharge day management is reported.
“TCM can run through my own surgical global period.” CMS does not pay TCM when any of the 30 days falls inside a global surgery period for a procedure billed by the same practitioner.
Where chronic care management fits after a discharge
Companian does not offer transitional care management. A qualifying patient can receive CCM during the TCM period without counting time or effort twice; the TCM visit can serve as the CCM initiating visit when the billing practitioner performs it and discusses CCM.
Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license. See chronic care management for physician practices.
Key takeaways
- The TCM face-to-face visit is part of TCM and is never billed as a separate E/M.
- A high-complexity patient seen 8 to 14 calendar days after discharge can still be billed as 99495.
- Each claim needs a contact, or two documented attempts, within 2 business days, medication reconciliation by the visit, and a visit inside the code’s window.
- CCM can be reported during the TCM period when no time or effort is counted toward both.
- The practitioner who bills APCM cannot bill TCM for that patient in the same month.
Questions about TCM requirements
What is transitional care management in medical billing?
Transitional care management (TCM) is the Medicare service for the 30-day period that starts on the day of a facility discharge. One claim, CPT 99495 or 99496, covers the 2-business-day contact, the face-to-face visit, medication reconciliation and the follow-up work.
What is the difference between 99495 and 99496?
Both require contact within 2 business days of discharge. 99495 needs at least moderate medical decision making and a visit within 14 calendar days; 99496 needs high-complexity decision making and a visit within 7 calendar days.
What is the CPT code for transition of care?
For Medicare, a transition from a hospital or other facility back to a community setting is billed as transitional care management, CPT 99495 or 99496, only when every TCM requirement is met.
Can the TCM face-to-face visit be done by telehealth?
It can, when the patient is eligible for Medicare telehealth. CMS lists 99495 and 99496 as codes it pays through telehealth, and the visit still has to fall within its code’s window.
Who can bill transitional care management?
A physician of any specialty can bill it, and so can a certified nurse-midwife, clinical nurse specialist, nurse practitioner or physician assistant authorized in their state. Only one of them may report TCM for a given period.
Does a skilled nursing facility discharge qualify for TCM?
Yes. A skilled nursing facility is one of the seven settings whose discharge starts the TCM period, when the patient then returns to a community setting such as a home or an assisted living facility and the other TCM requirements are met.
TCM (99495 or 99496) covers a 30-day discharge period. CCM (99490, 99439) covers care-management work per calendar month and may overlap that period when its requirements are met and no time or effort counts twice. Companian does not offer TCM.
Sources
- CMS, Transitional Care Management Services (MLN908628), August 2025
- CMS, Chronic Care Management Services (MLN909188), June 2025
- CMS, FAQs on Practitioner Billing for Chronic Care Management Services
- Federal Register, CY 2025 Physician Fee Schedule final rule
- CMS, FAQ on CHI and PIN services, March 2026
Read more: CCM CPT codes 99490 and 99439 · What conditions qualify for chronic care management
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